POL:08:PP:031:05:NIBT PAGE 1 of 6

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1 POL:08:PP:031:05:NIBT PAGE 1 of 6 Northern Ireland Blood Transfusion Service POLICY DOCUMENT Document Details Document Number: POL:08:PP:031:05:NIBT No. of Appendices: NONE Supersedes Number: POL:08:PP:031:04:NIBT Document Title: CORPORATE TRAINING POLICY ISSUE DATE: 6 MARCH 2013 EFFECTIVE DATE: 3 APRIL 2013 Document Authorisation Written By: Jenny Calvert Personnel and Training Manager Authorised By: Ivan Ritchie Head of HR & Corporate Services Authorised By: Dr Kieran Morris Chief Executive Date: Date: Date : CROSS REFERENCES This Policy refers to the following documents: Doc Type Doc. No. Title SOP BD:058 Individual Staff Training SOP DM:005 Medical Officer / Consultant Training Procedure SOP FD:006 Finance Staff Training Procedure SOP LS:001 Laboratory Training and Competency Procedure SOP PE:002 HR & Corporate services Training and Competency Procedure SOP QA:091 Quality Training Procedure SOP PE:008 New Modules of e-learning and review of existing modules POL PP:021 Knowledge & Skills Framework Policy

2 POL:08:PP:031:05:NIBT PAGE 2 of 6 Key Change From Previous Revision: Added reference to new SOP at 2.1 (7) Added information about e-learning at STATEMENT NIBTS POLICY FOR CORPORATE TRAINNG This Policy should be read in conjunction with the Knowledge and Skills Framework (KSF) Policy (ref POL:PP:021) which is central to the Agency s commitment to the staff review process. The policy sets out the training requirements in NIBTS with respect to compliance with relevant legislation and regulations. Under the Blood Safety and Quality Regulations 2005/50 there is a legal responsibility that staff are qualified for tasks which they perform. There is also a requirement that training is periodic, timely and relevant and that there is practical assessment of the effectiveness of training. NIBTS also requires to comply with the requirements of the Human Tissue Authority with respect to the Belfast Cord Blood Bank. With respect to the laboratory diagnostic service NIBTS must meet the standards for Clinical Pathology Accreditation. A common approach to training will be applied for all departments thus ensuring compliance with all legislation and regulations affecting the Service s activities. 2 OVERVIEW 2.1 This training policy sets out the resources, responsibilities and links to other procedural documents and specific BSQR requirements in relation to training. This policy has supporting SOP documents detailing arrangements for training across departments within the Service. These are listed as follows: 1) SOP:BD:058 Individual Staff Training on Training for Donor Services, Author: Donor Services General Manager. 2) SOP:LS:001 Laboratory Training and Competency Procedure on Training for Laboratory Services, Author: Laboratory Manager. 3) SOP:QA:091 Quality Training Procedure on Training for Quality Department & Regulatory Affairs and Compliance Department, Author: Quality Manager & RA & C Manager. 4) SOP:PE:002 HR & Corporate services Training and Competency Procedure on Training for HR & Corporate Services, Author: Head of HR & Corporate Service

3 POL:08:PP:031:05:NIBT PAGE 3 of 6 5) SOP:FD:006 Finance Staff Training Procedure on Training for Finance and IM&T Services, Author: Finance Manager. 6) SOP:DM:005 Medical Officer / Consultant Training Procedure on Training for Medical Staff, Author: Medial Director. 7) SOP PE:008 should be followed to introduce new topics / modules of e- learning and review existing modules. Complying with BSQR is necessary to maintain the NIBTS Blood Establishment Authorisation Licence. This corporate training plan sets out the resources, management responsibilities, links to other procedural documents and specific BSQR requirements in relation to training. 3 RESPONSIBILITY 3.1 Each member of staff has responsibility to maintain his/her training record. The section head or line manager will oversee staff members training record. The training record may be stored by the member of staff or the line manager. This detail is specified in the relevant department SOP. Oversight of training is provided by the Training and Clinical Audit sub-group of the Clinical Governance and Risk Management Committee. 4 POLICY 4.1 Resources for Training Current dedicated resources are a Band 5 Training Administration Manager in Corporate Services and a Band 7 Laboratory Training Officer in Laboratory Services. Other identified resources are training responsibilities contained within the job descriptions of various line managers and section heads. 4.2 Good Manufacturing Practice (GMP) Training and Assessment There is a BSQR requirement for all staff to receive GMP awareness training and assessment. At induction new staff should receive GMP awareness training within two weeks of commencing employment. This applies to all staff but GMP training awareness and assessment will be tailored as appropriate to the staff group or individual staff member. For example laboratory staff will be expected to have a more detailed knowledge of equipment maintenance schedules, calibration, reporting of deviations etc and an administrative and clerical member of staff will be required to be trained and assessed on SOPs and use the incident reporting system appropriately. The organisational requirement for provision of GMP training and assessment is annual and should be certified. The area of GMP training to be provided will be determined by information gathered in other areas such as incident reports and audits. The certificate should be entered into the staff members individual training record.

4 POL:08:PP:031:05:NIBT PAGE 4 of SOP Training New SOPs should be trained within 4 weeks of issue. Priority is given to training of new staff and where SOPs vary significantly from the previous existing version. It may be justified on the basis of a risk assessment to lengthen this time line especially for experienced members of staff and where SOPs change very little. This detail will be specified in the relevant department SOP. This is the responsibility of the line manager/section head and the decision should be documented and be accessible to the Quality Department. This detail will be specified in the relevant department SOP. A list of SOPs / training matrix should be entered into the staff member s individual training record with an assessment framework supporting this. 4.4 E-learning E-learning is the delivery of training using a web based system. It allows a wide range of topics to be covered and includes mechanisms for assessment / certification. A link to the IT system is on the intranet site. Line managers will assist the course owner to ensure individuals complete relevant e-learning modules. These modules must be completed by all relevant staff within the timescale specified by the course owner. Where access to e-learning is not available, other methods of training will be provided by the course owner. 4.5 Assessment Framework Staff training should be assessed to give assurance that training is effective. There are various assessment tools which may be used and the following are suggested for consideration. Participation in National External Quality Assurance Scheme exercises. Internal quality assurance exercises. Written assessment of training provided. Visual assessment or observation of tasks being performed. Oral questioning of staff member after training. Ongoing monitoring of staff performance. Review of quality incidents related to training post. The assessment framework should be appropriate for the staff group or individual staff member. For example, for a laboratory assistant in component processing assessment on the use of the Compomat and filtration of red cells by direct observation would be appropriate and for blood collection staff who undertake personal donor interviews a written assessment with a predefined pass mark threshold is recommended. It is not expected that every SOP is assessed every time but the assessment framework should be scheduled and informed by risk assessment. Competency assessments should be entered in the individual staff member s training record.

5 POL:08:PP:031:05:NIBT PAGE 5 of Training Records Individual training records are required and should contain the following elements. Essential elements are in bold type. 1 Induction programme - induction programme should include GMP awareness training. 2 Job description. 3 GMP training and assessment. 4 Relevant SOPs. 5 Assessment of relevant SOPs. 6 Mandatory training e.g. fire safety, manual handling, data protection etc 7 CPD portfolio for certain professional groups e.g. biomedical scientists and nursing staff. 8 Training programme. 9 Personal development review records. 10 Optional curriculum vitae or academic history. 4.7 Individual Training Programme Each staff member should have an individual training programme informed by his/her KSF staff development review. This will identify training gaps and training needs for the following year and will include attendance at courses, conferences, professional development through development of new techniques, involvement in validation projects etc. Note there is a separate requirement for certain professional groups e.g. biomedical scientists and nurses to maintain registration with their professional bodies which includes participation in Continuous Professional Development (CPD) which is subject to periodic audit and review by the relevant professional body Health Professions Council and Nursing and Midwifery Council. 4.8 Timelines for Training and Assessment Staff should be trained and assessed on new SOPs within four weeks of issue. Staff members who have had absence of greater than 6 months should be trained on existing SOPs within four weeks of return to work. Where there is cumulative absence of 6 months in the preceding 12 months staff members should be trained and assessed on existing SOPs before 4 weeks. It may be justified on the basis of a risk assessment to lengthen this time line especially for experienced members of staff and where SOPs change very little. This is the responsibility of the line manager/section head and the decision should be documented and be accessible to the Quality Department. 5 EQUALITY SCREENING OUTCOME This policy has been drawn up and reviewed in light of the statutory obligations contained within Section 75 of the Northern Ireland Act (1998). In line with the statutory duty of equality this policy has been screened against particular criteria. If at any stage of the life of the policy there are any issues within the policy which are perceived by any

6 POL:08:PP:031:05:NIBT PAGE 6 of 6 party as creating adverse impacts on any of the groups under Section 75 that party should bring these to the attention of the Head of HR& Corporate Services. 6 TRAINING REQUIREMENTS Senior Managers/Department Managers/Section Heads must read and understand this policy. All staff must be made aware of this policy.